Non-Small Cell Lung Cancer Algorithm
Non-Small Cell Lung CancerPage 1 of 19This practice algorithm has been specifically developed for MD Anderson using a multidisciplinary approach and taking into consideration circumstances particular to MD Anderson,including the following: MD Anderson’s specific patient population; MD Anderson’s services and structure; and MD Anderson’s clinical information. Moreover, this algorithm is notintended to replace the independent medical or professional judgment of physicians or other health care providers. This algorithm should not be used to treat pregnant women.Note: Consider Clinical Trials as treatment options for eligible patients. This algorithm is based on TNM Staging VI.INITIAL EVALUATION1T1-2, N0(Stage I)1Pathology consistent withnon-small cell lung cancer History and physical Chest x-ray Laboratory studies toinclude hematologic andfull chemistry panels CT chest and upperabdomen ECG if history of heartdisease CLINICAL STAGEPRE-TREATMENT EVALUATIONCentrallesion?NoSee Page 2, centrallesion with negativemediastinal nodes orperipheral lesionYesT1-3, N0 (Stage I)T1-3, N1 (Stage II)PET scan(optionalfor T1,N0) Bronchoscopy MediastinoscopyT1-2, N1(Stage II)orendobronchial ultrasoundfine needle aspiration(EBUS-FNA) Brain MRI for symptomaticpatients T1-2, N0 Pulmonary function testsT3, N0 (Stage IIB)See Page 3, box AT3, N1 (Stage IIIA)See Page 3, box 1-3, N2 (Stage IIIA)See Page 4,box BT1-3, N3 (Stage IIIB)See Page 5,box CConsider MD Anderson approved Thoracic biomarkers Copyright 2017 The University of Texas MD Anderson Cancer CenterDepartment of Clinical Effectiveness V12Approved by The Executive Committee of Medical Staff on 04/25/2017
Non-Small Cell Lung CancerPage 2 of 19This practice algorithm has been specifically developed for MD Anderson using a multidisciplinary approach and taking into consideration circumstances particular to MD Anderson,including the following: MD Anderson’s specific patient population; MD Anderson’s services and structure; and MD Anderson’s clinical information. Moreover, this algorithm is notintended to replace the independent medical or professional judgment of physicians or other health care providers. This algorithm should not be used to treat pregnant women.Note: Consider Clinical Trials as treatment options for eligible patients. This algorithm is based on TNM Staging VI.PRE-TREATMENT EVALUATIONCentral lesion withnegative mediastinalnodes or peripherallesion1Stereotactic body radiation therapy Conventional definitive radiationtherapy Consider local ablation therapy POST-OPERATIVE SURGICAL FINDINGST1, N0(Stage IA)Marginsnegative Reresection or Consider concurrentchemotherapy/radiation therapy MarginspositiveNoMedicallyoperable?T2, N0(Stage 1B)T1-2, N1(Stage IIA-B)Marginsnegative MarginspositiveYes Surgical explorationand resectionIn case of small (less than or equal to 2 cm) peripheral lesions that will undergo resection with acomplete mediastinal and hilar lymph node dissection, integrated PET/CT has a high negativepredictive value. EBUS-FNA is recommended but not required.2High risk patients display poorly differentiated tumors, vascular invasion, wedge resection,tumors greater than 4 cm, visceral pleural involvement, and unknown lymph node status3Platinum-based doublet therapy for selected patients4Radiation therapy alone or concurrent chemoradiation5Either concurrent radiation therapy followed by 2 cycles of posterior chemotherapy or 2 cycles ofinduction chemotherapy followed by concurrent chemoradiationCopyright 2017 The University of Texas MD Anderson Cancer CenterUnresectableObserve orAdjuvantchemotherapy inhigh risk patients2Observation (excluding T1-2, N1) orAdjuvant chemotherapy3Consider re-resection followed byPost-op adjuvant therapy: radiationtherapy4 followed by chemotherapy3 orchemotherapy3 followed by radiationtherapy4Margins negative andno extracapsular spreadAdjuvant chemotherapy3followed by radiation therapy4Margins positive orextracapsular spreadPost-op adjuvant therapy:radiation therapy4 followed bychemotherapy3 or chemotherapy3followed by radiation therapy4T1-2, N2-3(Stage IIIA-B)1 Surveillance,see Page 7Radiation therapy or chemoradiation5 for selected patientsDepartment of Clinical Effectiveness V12Approved by The Executive Committee of Medical Staff on 04/25/2017
Non-Small Cell Lung CancerPage 3 of 19This practice algorithm has been specifically developed for MD Anderson using a multidisciplinary approach and taking into consideration circumstances particular to MD Anderson,including the following: MD Anderson’s specific patient population; MD Anderson’s services and structure; and MD Anderson’s clinical information. Moreover, this algorithm is notintended to replace the independent medical or professional judgment of physicians or other health care providers. This algorithm should not be used to treat pregnant women.Note: Consider Clinical Trials as treatment options for eligible patients. This algorithm is based on TNM Staging VI.CLINICALEVALUATIONCLINICAL PRE-TREATMENTSTAGEEVALUATIONINITIAL TREATMENTAdjuvant chemoradiation1SurgeryBronchoscopyMediastinoscopy orEBUS-FNA MRI brain MRI of spine plusthoracic inlet forsuperior sulcus lesions(sup-sulcus protocol) PET scan Pulmonary functiontestsResectable AT3, N0(Stage IIB)T3, N1(Stage IIIA)by CT Induction concurrent chemoradiationSuperior sulcustumor(T3-4, N0-1)Definitive chemoradiation1UnresectableInduction nallyresectableInduction chemotherapyNoSurgeryResectableMargins positiveYesCentral T3 tumor orchest wall invasion(i.e., T3 other thansuperior sulcus)Induction chemotherapy or Induction concurrentchemoradiation See Page 6, box EUnresectableResectableSurgeryUnresectableComplete definitivechemoradiationRadiation therapy3SurgeryMargins negativeDistantmetastasis?SurgerySurveillance,see Page 7Adjuvant chemotherapy2Post-op adjuvant therapy:32 Radiation therapy followed by chemotherapyor23 Chemotherapy followed by radiation Complete definitivechemoradiation1Either concurrent radiation therapy followed by 2 cycles of posterior chemotherapy or 2 cycles of induction chemotherapy followed by concurrent chemoradiationPlatinum-based doublet therapy for selected patients3Radiation therapy alone or concurrent chemoradiation2Copyright 2017 The University of Texas MD Anderson Cancer CenterDepartment of Clinical Effectiveness V12Approved by The Executive Committee of Medical Staff on 04/25/2017
Non-Small Cell Lung CancerPage 4 of 19This practice algorithm has been specifically developed for MD Anderson using a multidisciplinary approach and taking into consideration circumstances particular to MD Anderson,including the following: MD Anderson’s specific patient population; MD Anderson’s services and structure; and MD Anderson’s clinical information. Moreover, this algorithm is notintended to replace the independent medical or professional judgment of physicians or other health care providers. This algorithm should not be used to treat pregnant women.Note: Consider Clinical Trials as treatment options for eligible patients. This algorithm is based on TNM Staging VI.PRE-TREATMENT EVALUATIONCLINICALSTAGEB MRIT1-3, N2(Stage IIIA)brainscan Pulmonaryfunction tests PETINITIAL AND ADJUVANT TREATMENTPleural/pericardialeffusionSee Page 6, box DDistant metastasisSee Page 6, box E Adjuvantchemotherapy Surveillance if T1-2, N0N0-1N3 diseaseSee Page 5, box CClinical N2diseaseAdjuvant chemotherapy1followed by radiation therapy2N2-3N2, N3 nodesnegativeSurgical resection with mediastinallymph node dissectionMarginspositive Bronchoscopy EBUS-FNA Considermediastinoscopyif EBUS-FNAnegativeN2 nodespositiveInductionchemotherapyversus uationResectablePost-op adjuvant therapy:2 Radiation therapy followed3by chemotherapy or3 Chemotherapy followed byradiation therapy2Surveillancesee Page 7Complete definitivechemoradiationSurgical resectionwith adjuvant radiation,if eligibleDefinitive chemoradiation41Concurrent chemoradiation for gross residual diseaseRadiation therapy alone or concurrent chemoradiation3Platinum-based doublet therapy for selected patients4Either concurrent radiation therapy followed by 2 cycles of posteriorchemotherapy or 2 cycles of induction chemotherapy followed byconcurrent chemoradiation2Copyright 2017 The University of Texas MD Anderson Cancer CenterN3 nodespositiveMetastasisSee Page 5, box CSee Page 6, box EDepartment of Clinical Effectiveness V12Approved by The Executive Committee of Medical Staff on 04/25/2017
Non-Small Cell Lung CancerPage 5 of 19This practice algorithm has been specifically developed for MD Anderson using a multidisciplinary approach and taking into consideration circumstances particular to MD Anderson,including the following: MD Anderson’s specific patient population; MD Anderson’s services and structure; and MD Anderson’s clinical information. Moreover, this algorithm is notintended to replace the independent medical or professional judgment of physicians or other health care providers. This algorithm should not be used to treat pregnant women.Note: Consider Clinical Trials as treatment options for eligible patients. This algorithm is based on TNM Staging VI.CLINICALSTAGE PETCT1-3, N3 (Stage IIIB)INITIAL AND ADJUVANT TREATMENTPRE-TREATMENTEVALUATIONscan MRI brain Pathological confirmationof equivocal N3 disease by: Needle biopsy Supraclavicular lymphnode biopsy Mediastinoscopy Thoracoscopy MediastinotomyN3 ruled outSee initial treatment for stage I-IIIA on Page 1Definitive chemoradiation1N3 confirmedDistant metastasis or malignant pleural effusion. See Page 6, box E Surgery Adjuvant chemoradiation1in high risk patients2Adjuvant chemotherapyResectable MRI brainPET scan MRI of spine, asclinically indicated Bronchoscopy Mediastinoscopy Pulmonary function tests T4, N0-1 (Stage IIIB)(see Page 6, box ction concurrent chemoradiation orInduction chemotherapySurveillance,see Page 7SurgeryDefinitive chemoradiation1 Induction chemotherapyConcurrent e definitivechemoradiationSurgicalre-evaluationSee Page 6, box EEither concurrent radiation therapy followed by 2 cycles of posterior chemotherapy or 2 cycles of induction chemotherapy followed by concurrent chemoradiationHigh risk patients display poorly differentiated tumors, vascular invasion, wedge resection, tumors greater than 4 cm, visceral pleural involvement, and unknown lymph node statusCopyright 2017 The University of Texas MD Anderson Cancer CenterDepartment of Clinical Effectiveness V12Approved by The Executive Committee of Medical Staff on 04/25/2017
Non-Small Cell Lung CancerPage 6 of 19This practice algorithm has been specifically developed for MD Anderson using a multidisciplinary approach and taking into consideration circumstances particular to MD Anderson,including the following: MD Anderson’s specific patient population; MD Anderson’s services and structure; and MD Anderson’s clinical information. Moreover, this algorithm is notintended to replace the independent medical or professional judgment of physicians or other health care providers. This algorithm should not be used to treat pregnant women.Note: Consider Clinical Trials as treatment options for eligible patients. This algorithm is based on TNM Staging VI.PRE-TREATMENTEVALUATIONCLINICALSTAGEINITIAL AND ADJUVANT TREATMENTBenignDPleural/pericardialeffusion Thoracentesis orpericardiocentesis, if indicatedThoracoscopy, if thoracentesisindeterminate Malignant Solitary brain metastasisEMetastasisStage IVSolitary metastasis elsewhereTreatment according to T and N stage Treatment for distant metastasis or malignantpleural effusionIf pleural effusion is recurrent, consider eitherpleurodesis or indwelling pleural catheterResect brain lesion with orwithout whole brain radiation therapy orStereotactic radiosurgery with orwithout whole brain radiation therapyConsider local ablation surgery,radiofrequency ablation (RFA), stereotacticbody radiation therapy (SBRT)Multiple metastatic diseaseNo metastasisCopyright 2017 The University of Texas MD Anderson Cancer CenterSystemic chemotherapy withor without palliative radiationtherapy (see principles ofradiation therapy andchemotherapy)Surveillance,see Page 7Workup as clinically indicatedDepartment of Clinical Effectiveness V12Approved by The Executive Committee of Medical Staff on 04/25/2017
Non-Small Cell Lung CancerPage 7 of 19This practice algorithm has been specifically developed for MD Anderson using a multidisciplinary approach and taking into consideration circumstances particular to MD Anderson,including the following: MD Anderson’s specific patient population; MD Anderson’s services and structure; and MD Anderson’s clinical information. Moreover, this algorithm is notintended to replace the independent medical or professional judgment of physicians or other health care providers. This algorithm should not be used to treat pregnant women.Note: Consider Clinical Trials as treatment options for eligible patients. This algorithm is based on TNM Staging VI.THERAPY FOR RECURRENCE AND METASTASISSURVEILLANCELocoregional recurrenceYes PhysicalStages I and IIexam every 6 monthsfor 5 years CT chest every 6 months for2 years, then annuallyRecurrenceor secondprimary?Second primaryNoStages IIIStage IVPhysical exam and CT chestevery 2 – 3 months for2 years, then every 6 monthsfor 3 years, then annuallyPhysical exam and scans ofinvolved sites every2 – 3 months or as clinicallyindicatedCopyright 2017 The University of Texas MD Anderson Cancer CenterDistant metastasisRecurrenceor secondprimary?See Page 6, box EIndividualized treatmentIndividualized treatmentSecondprimary?NoNo Evaluate for surgical resection orChemoradiationContinue with surveillanceYesYes See Page 6, box EContinue with surveillanceDepartment of Clinical Effectiveness V12Approved by The Executive Committee of Medical Staff on 04/25/2017
Non-Small Cell Lung CancerPage 8 of 19This practice algorithm has been specifically developed for MD Anderson using a multidisciplinary approach and taking into consideration circumstances particular to MD Anderson,including the following: MD Anderson’s specific patient population; MD Anderson’s services and structure; and MD Anderson’s clinical information. Moreover, this algorithm is notintended to replace the independent medical or professional judgment of physicians or other health care providers. This algorithm should not be used to treat pregnant women.Note: Consider Clinical Trials as treatment options for eligible patients. This algorithm is based on TNM Staging VI.PRINCIPLES OF CHEMOTHERAPY FOR PATIENTS WITH STAGE III DISEASE RECEIVING CHEMORADIATION Patients with inoperable stage III disease should be offered definitive concurrent chemoradiation with curative intent, which provides superior survival over radiation therapy alone.Concurrent chemoradiation should be used only in patients with a suitable performance status (PS) who have not had excessive weight loss prior to starting treatment (i.e., PS 0-1and with less than or equal to 5 – 10% weight loss).Patients in need of immediate radiation therapy for symptom palliation (i.e., those with symptomatic bronchial obstruction, superior vena cava (SVC) obstruction, pain, etc.) shouldbegin treatment with concurrent chemoradiation, followed by 2 additional cycles of chemotherapy upon completion of their concurrent chemoradiation.For patients who do not need immediate radiation therapy for symptom palliation, acceptable sequencing of their chemoradiation is as follows:- 2 cycles of induction chemotherapy, followed by concurrent chemoradiation or- Concurrent chemoradiation, and followed by 2 additional cycles of chemotherapy upon completion of their concurrent chemoradiation (“posterior chemotherapy”)Acceptable chemotherapy regimens for induction and/or “posterior” chemotherapy include:- Paclitaxel 200 mg/m2 IV plus carboplatin AUC 6 IV, every 21 days- Paclitaxel 200 mg/m2 IV plus cisplatin 75 mg/m2 IV, every 21 days- Docetaxel 75 mg/m2 IV plus carboplatin AUC 6 IV, every 21 days- Docetaxel 75 mg/m2 IV plus cisplatin 75 mg/m2 IV, every 21 days- Cisplatin 60 – 80 mg/m2 IV day 1 plus etoposide 80 – 120 mg/m2 IV days 1 – 3, every 21 daysAcceptable chemotherapy regimens for the concurrent chemoradiation phase of treatment include:- Paclitaxel 50 mg/m2 IV plus carboplatin AUC 2 IV, weekly during radiation therapy- Docetaxel 20 – 25 mg/m2 IV plus carboplatin AUC 2 IV, weekly during radiation therapy- Docetaxel 20 – 25 mg/m2 IV plus cisplatin 20 – 25 mg/m2 IV, weekly during radiation therapy- Cisplatin 50 mg/m2 IV days 1, 8 and days 29, 36 plus etoposide 50 mg/m2 IV days 1 – 5 and days 29 – 33In patients receiving radiation therapy or chemoradiation with curative intent, treatment interruptions or dose reductions for temporary and manageable toxicities, such asesophagitis or myelosuppression, should be avoided. Careful patient monitoring and aggressive supportive care are preferable to treatment breaks in potentially curablepatients. Patients should be evaluated at least once per every 5 fractions to monitor weight changes and toxicity.Copyright 2017 The University of Texas MD Anderson Cancer CenterDepartment of Clinical Effectiveness V12Approved by The Executive Committee of Medical Staff on 04/25/2017
Non-Small Cell Lung CancerPage 9 of 19This practice algorithm has been specifically developed for MD Anderson using a multidisciplinary approach and taking into consideration circumstances particular to MD Anderson,including the following: MD Anderson’s specific patient population; MD Anderson’s services and structure; and MD Anderson’s clinical information. Moreover, this algorithm is notintended to replace the independent medical or professional judgment of physicians or other health care providers. This algorithm should not be used to treat pregnant women.Note: Consider Clinical Trials as treatment options for eligible patients. This algorithm is based on TNM Staging VI.PRINCIPLES OF CHEMOTHERAPY FOR PATIENTS WITH STAGES IIIB (EFFUSION) AND IV DISEASEFirst-line chemotherapyPlatinum-based combination chemotherapy prolongs survival and improves symptoms and quality of life compared to best supportive care for patients with acceptable PS.Platinum-based combination chemotherapy should be offered to all patients with PS of 0 – 1, and to selected patients with PS of 2. Patients with PS of 3 – 4 benefit little, if any, from cytotoxic chemotherapy. Elderly patients with acceptable PS should be offered chemotherapy, either combination platinum-based therapy or single-agent therapy (depending upon patient’s age andco-morbid conditions). Most platinum-based combination regimens yielded similar response rates (25% – 35%) and survival (median: 8 – 10 months; 1 year: 30% – 40%; 2 year: 10% – 15%). Acceptable first-line chemotherapy regimens include:2 Paclitaxel 200 mg/m IV plus carboplatin AUC 6 IV, every 21 days22 Paclitaxel 200 mg/m IV plus cisplatin 75 mg/m IV, every 21 days2 Docetaxel 75 mg/m IV plus carboplatin AUC 6 IV, every 21 days22 Docetaxel 75 mg/m IV plus cisplatin 75 mg/m IV, every 21 days22 Gemcitabine 1,000 mg/m IV days 1, 8 (plus or minus day 15) plus cisplatin 75 mg/m IV day 1, every 21 days (if using day 1/8 gemcitabine schedule) or every 28 days (if usingday 1/8/15 gemcitabine schedule)2 Gemcitabine 1,200 mg/m IV days 1, 8 plus carboplatin AUC 5 IV day 1, every 21 days22 Vinorelbine 25 – 30 mg/m IV days 1, 8, and 15 plus cisplatin 80 – 100 mg/m IV day 1, every 28 days22 Cisplati
PRE-TREATMENT EVALUATION INITIAL AND ADJUVANT TREATMENT Bronchoscopy EBUS-FNA Consider mediastinoscopy if EBUS-FNA negative MRI brain PET scan Pulmonary function tests B N3 nodes positive See Page 6, box E N2, N3 nodes negative Induction chemotherapy versus induction chemoradiation N0-1 Complete definitive chemoradiation
Non Small Cell Lung Cancer (NSCLC) Lung cancer is responsible for 1 in 7 new cases of cancer and is responsible for 22% of all cancer deaths. Approximately 80% of patients have non-small cell lung cancer (NSCLC), of whom about 20% have early-stage disease (AJCC Stage I, TNM Stage T1-2N0M0) which is associated with the best chance of cure. Lung
Non-small cell lung cancer is the most common type of lung cancer and accounts for 84% of cases. There are different types of non-small cell lung cancer, including: Adenocarcinoma - a cancer that forms in the outer parts of the lung. Squamous cell carcinoma - a cancer that forms from a cell lining the airway.
11/15/2011 4 Lung Cancer Facts Lung cancer accounts for more deaths than any other cancer in both men and women. Since 1987, more women have died each year from lung cancer than from breast cancer. Lung cancer causes more deaths than the next three common cancers combined (colon, breast, prostate). Smoking contributes to 80% and 90% of lung cancer deaths in
Primary lung cancer remains the most common malignancy after non-melanocytic skin cancer, and deaths from lung cancer exceed those from any other malignancy worldwide [1]. In 2012, lung cancer was the most frequently diagnosed cancer in males with an estimated 1.2 million incident cases worldwide. Among females, lung cancer was the leading
Lung cancer screening: the cost of inaction 2 Table of contents Executive summary 3 1 Introduction 7 2 Lung cancer: a public health priority 9 3 Earlier detection: the key to reducing the burden of lung cancer 12 4 LDCT screening for lung cancer: the next big opportunity in cancer detection 18 5 An investment in health system sustainability 21 6 Ensuring successful implementation of lung cancer
Lung Cancer Canada is a national charitable organization that serves as Canada's leading resource for lung cancer education, patient support, research and advocacy. Based in Toronto, Ontario, Lung Cancer Canada has a wide reach that includes both regional and pan-Canadian initiatives. Lung Cancer Canada is a member of the Global Lung Cancer
lung by the process of 'metastasis'-which produces agency (as cancer cells) from initial site of disease to another part of body [7]. Most cancers also known as primary lung cancers are carcinomas which start it in the lungs [8]. There are two main types are carcinoma 1) small-cell lung cancer and 2) non-small-cell lung cancer [9].
Non-small cell lung cancer (NSCLC) is the most common type of lung cancer. It grows more slowly than small cell lung cancer. Once your doctor has determined the stage of your cancer, the next step is deciding on appropriate treatment options together with your doctor. Depending on your specific case, you may receive additional tests to learn .
